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(i) The role of the participant researcher.

As already identified above, some issues exist around the collection of data by a member of the clinical team who also participated in the PMP. On the positive side, the researcher was known to the patients and had detailed insight into both the programme content and the dynamics of each group. Patients were encouraged to identify aspects of the programme that they found helpful but also to make

constructive criticism where they felt this to be appropriate. This was promoted on the basis that one of the aims of the research was to identify areas for improvement in the programme.

As stated above, the researcher believed patients felt comfortable with the interview process and several reported finding the process useful, both in terms of

consolidation of, and reflection upon, what they had learned. Some recognition needs to be made, however, that interview by a participant researcher as opposed to a researcher unknown to patients may have had some influence on the nature of the data obtained. It is possible that patients felt under some pressure to report “key moments” of change as somehow more significant than they really were to them. They may have reported certain things simply because they remembered them occurring, possibly in order to “please” the participant researcher. On the basis of the way in which key moments were reported however, particularly in the way that information was backed up with other relevant material, the researcher felt confident that events reported as “key moments” were genuinely meaningful to patients.

(ii) The ratio of women to men in the sample

The sample of women attending PMPs typically outnumbers men on a ratio of 2:1. (based on unpublished sample of 5000 patients who attended INPUT at St Thomas' Hospital; Williams, personal communication). The sample of thirty in this study included only three men and it was felt that this could have had some implications

for the reported findings if men and women were found to respond differently to the question of “key moments” in some way. The bias towards women in the sample might therefore obscure some aspect of the findings. However, on surveying the data from the three male programme-participants (patients 2,15 and 29), there do not appear to be any obvious differences between the data obtained from male and female participants in terms of number or type of key moments and their

relationship with objective measures. For example, the men identify the achievement of an articulated working model of pain, reflecting on their own experience of change, including thoughts and feelings, and on the communal experience of participating in a PMP. One man improved and two partially improved on objective measures. Additional male participants in the group might have

resulted in different types of “key moments" being accessed but on the basis of existing data, there is little evidence to suggest a difference between the male and the female experience of PMP participation. The sample would therefore seem to be reasonably representative.

(ill) The relationship between the experience of “key moments” and the capacity to identify and articulate them.

A method which relies on people's capacity to articulate what they have learned may have some limitations. Patients were interviewed for up to one-and-a-half hours and in most cases, large amounts of information were obtained. The “key moments” section constituted the culmination of the interview for the purposes of the current research but was actually a relatively small part of the whole interview. On

reviewing the raw data, two possible concerns emerge:

1 ) There are examples of patients who improved well on objective measures but were not particularly articulate in terms of “key moments” (2-3 identified, as opposed to 5 or more). It would be anticipated that some patients may be less able to

articulate their thoughts than others, or that for some, change may be occurring at a level that they cannot readily access. This suggests that the “key moments” measure has some limitations in terms of its association with the objective measures recorded by patients who have done well on the programme.

2) There are also examples of one or two patients who have made only partial change on the basis of objective measures but scored highly in terms of “key

moments”. Some of these patients might be recognised as being able to articulate the “right” answers but without having “internalised” the material. This is a further example of some of the limitations in the “key moment” methodology.

(iv) Timing of the data collection.

During the course of the data collection phase, a hugely significant world event occurred (the terrorist attacks on the World Trade Centre on September 11*^, 2001). The cohort of patients involved in the programme at the time provided a variety of insights into their personal experiences of that event in conjunction with participating on the PMP during their post-treatment interviews. The event impacted on several patients in a way that may have influenced their progress in learning pain

management strategies, particularly with respect to cognitive restructuring. Some of the key moments cited relate to individual's reflections on “September 11^” (see section 3.2).

Although not directly relevant to the current study, one or two taped interviews include some fascinating material regarding patients’ experience of this event. For example, one patient had a son working in the World Trade Centre and did not know his whereabouts for 24 hours after the attacks. She relates her experience of waiting for news and how she employed cognitive techniques learned on the PMP to help her.